Two economic writers tell Fiona Tyrrell promises made five years ago by the Government to improve the healthcare system are nowhere near fulfilled
Ireland's acute hospitals are like the Titanic, they are "adrift alone in the ocean and slowly sinking", according to one of the authors of a new book which analyses the problems facing the Irish healthcare system.
Under-resourced, under staffed, inequitable and frequently chaotic, the Irish healthcare system is in crisis, according to a new book published this month.
The book details how Ireland has one of the lowest health spending rates in Europe, how the consultants' contract is central to inequality in access to hospital care and how expanded acute hospital capacity is urgently needed.
How Ireland Cares is a revised and updated version of a report commissioned by the Irish Congress of Trade Unions. Authors, New York-based professor of economics A Dale Tussing and healthcare economist Maev-Ann Wren, carried out 100 interviews with health researchers and people working in the healthcare system while writing the book.
The book describes how access is based on ability to pay and not one's needs, how too many hospitals are staffed largely by junior doctors and there are too few family doctors, many of whom work in outmoded premises. The book also offers specific plans for reform with 80 detailed recommendations.
The problems of the Irish health service have come to be regarded as synonymous with the problems of acute hospitals, and more specifically with the problems of the crowded A&E departments, according to the authors.
Numbers waiting on trolleys State-wide regularly run to more than 200 or even 300 and they peaked at more than 400 in January 2005 and again in January this year.
There is evidence, they argue, that people are leaving A&E departments without medical attention. A nurse has described to the authors the experience of assessing a chest-pain patient as urgent, who, after six hours of waiting to be seen by a doctor, left the hospital and died within minutes in its car-park.
Overcrowding in A&E reflects inadequate bed capacity in the hospitals' wards, which in turn is exacerbated by inadequate capacity in institutions for long-stay patients who no longer need acute care and by inadequate supports in the community, the book argues.
A large part of what shows up as an A&E or acute hospital problem is the result of inadequacies in the rest of the system, particularly an outdated primary care system and lack of community care beds, explains Prof Tussing.
Immediate steps recommended to relieve the A&E crisis include opening any available public long-stay facilities, the establishment of acute medical units (AMUs) in all hospitals and lifting the cap on public health service employment. A long-term care system guaranteeing care to all citizens needs to be made a priority, they add.
In addition, a plan for expanded hospital capacity needs to be produced by the Health Service Executive beginning with a transparent and validated bed count, the book states.
The authors argue that inadequate acute bed capacity has reached crisis level, that the 2001 Health Strategy's targets for expanding capacity (3,000 additional acute beds over a 10-year period) have not been met and a growing and ageing population is going to make this crisis more severe.
If Ireland wished to have the EU average of 25.9 acute beds per 1,000 population over the age of 65, this would require adding 4,134 acute inpatients beds over the next 11 years - a 34 per cent increase on the present figure, the authors note.
Five years on and the promises of the 2001 Health Strategy are "nowhere near fulfilled," according to Ms Wren.
"Instead there has been a tight restraint on health service employment since just after the 2002 general election. Promised long-stay facilities and community nursing units have not been delivered. Obfuscation has attempted to hide the very poor record of delivery of additional acute care beds.
"The primary care strategy stalled for five years with only 10 valiant but isolated pilot projects," she says.
The modernisation of the primary care system, is critical, according to Prof Tussing. He cites the fact that more than 60 per cent of Irish GPs are working in one or two-handed GP practices. A modern primary care system would take a lot of pressure off acute hospitals, he says.
The general consensus among people the authors had spoken to was that the primary care strategy had been abandoned, he added. Had the 10-year primary care strategy been implemented in 2005 it would have cost €165 million, according to the authors.
Aside from a capacity problem, Irish public hospitals operate in an "extraordinary environment of institutionalised discrimination between patients", according to the authors.
They describe the two-tier system of access to public hospitals as a "socially divisive anachronism, which has no place in a civilised state".
Criticising the consultants' common contract the authors describe how consultants are paid a public salary for being present in public hospitals for at least 33 hours per week, but need not care for public patients during all or any of that time.
"They are permitted private practices in public hospitals, and time spent treating private patients for fees can count towards their 33 salaried hours. Consultants are not accountable to anyone, either administratively or clinically."
The authors recommend a reform of the consultants' contract describing it as "central to inequity in access to hospital care" and "an obstacle to rational management in Irish hospitals".
A reformed contract should provide for clinical and administrative accountability, should require all consultants to treat patients according to need, drawn from a common waiting list and should require all consultants to work as rostered members of teams, answerable to a head of department or clinical director, who is in turn answerable to the hospital/hospital group's chief executive officer.
The consultants' contract negotiations have the potential to deliver historic reform, the authors conclude. "Without contract reform, the system will remain inequitable, unsafe and unmanageable," they say.
Following cutbacks in the late 1980s and early 1990s, spending on health has increased significantly in recent years and Ireland now spends 8.9 per cent of GNP on health. It is still, however, according to the authors, below the EU average.
The book also calls for the Government to abandon its plan to allow private hospitals to be built on the grounds of public hospital facilities. The move could have seriously damaging effects on public health services, the authors argue, and will increase private beds at the taxpayers' expense.
In addition, it could further disadvantage public patients, channel private patients into institutions, which offer inferior care, and undermine the staffing and management of public hospitals.
Among a wide range of other recommendations made in the report are the lifting of the cap on recruitment in the health sector, implementation of the Hanly report, free primary care for all and the introduction of risk equalisation in the Irish health insurance market.
How Ireland Cares by A Dale Tussing and Maev-Ann Wren is published by New Island. Price €29.95.